With early voting underway, Democratic challengers are relentlessly pushing the issue on the air, on the campaign trail and on debate stages. And Republican incumbents, many facing their first real races in a long time, are moving to defend their records after years of GOP orthodoxy against the Affordable Care Act, while also seeking to paint their opponents’ health care views as too extreme.

The health care battle is unfolding most sharply in the state’s three biggest U.S. House contests, where Democrats are mounting highly competitive bids to unseat GOP U.S. Reps. John Culberson of Houston, Will Hurd of Helotes and Pete Sessions of Dallas. But the fight is also spilling into the U.S. Senate contest and House matchups in traditionally Republican territory.

Buoyed by poll numbers and Republicans’ defensive moves, Democrats are convinced health care will be decisive this November.

“It’s our view this election is a health care election,” said Amanda Harrington, a spokeswoman for Protect Our Care, a pro-Obamacare group that has done polling in Culberson’s and Sessions’ districts. “Republicans know they’re on the wrong side of this issue, and they’re scrambling to make up for lost time.”

Harrington and other Democrats point to things like Sessions earlier this month introducing a nonbinding resolution to protect people with pre-existing conditions — a provision at the heart of Democrats’ health care messaging this cycle. Sessions’ opponent, Colin Allred, denounced the resolution as a pre-election Hail Mary, calling it the “worst kind of Washington politics.”

Republicans, though, see ample opportunity to play offense on the issue, too. Texas GOP Chairman James Dickey said in an interview that there is “no question” that the best response to Democrats’ health care attacks is to emphasize the proposals coming from some in their party that would grow the government’s role in the system.

After Obamacare, “the next Democrat solution is to bankrupt the entire country even faster by doing ‘Medicare for All,’ which [is] projected to cost over $32 trillion over the next 10 years and still would not solve the problem,” Dickey said, referring to a July study from a libertarian think tank. “The issue is that health insurance spending needs to be fixed, and every time Democrats double down on government involvement and manipulation of the health insurance market, they only serve to make it worse.”

Republicans’ years-long push to dismantle Obamacare came to a head last year with the American Health Care Act, which passed the House but died in the Senate. Every House Republican from Texas voted for the legislation except for Hurd — and even then, his split from his party has done little to shield him from Democrats’ health care offensive. His opponent, Gina Ortiz Jones, has blanketed the airwaves with ads focusing on the eight votes he cast in opposition to Obamacare prior to the AHCA debate — votes, he has argued, that were on bills “substantively different” from the AHCA.

Still, Jones’ ads underscore just how aggressive the Democratic drive to own health care has become in Texas. The debate has an additional layer in the state, where Attorney General Ken Paxton is leading a multi-state lawsuit to finish off the Affordable Care Act — which the Trump administration has declined to defend in response.

The issue is also factoring into the fight at the top of the ticket, where U.S. Rep. Beto O’Rourke, D-El Paso, is mounting a serious bid to unseat Republican U.S. Sen. Ted Cruz — arguably the fiercest Obamacare opponent in Congress. Cruz has insisted in recent weeks that “everyone agrees” on the need to protect those with pre-existing conditions, a comment that has drawn derision from Democrats who cite his longtime vow to “repeal every single word of Obamacare” and his leading role in the 2013 government shutdown over the law.

“Ted Cruz has voted to take away health care from millions of American families,” O’Rourke says in a TV ad. “He’s voted repeatedly to roll back protections for pre-existing conditions. And he shut down the government for 16 days because he thought too many had too much health care.”

Health care is set to become an even bigger topic in the final week of the race, with a new anti-Cruz super PAC on Thursday announcing a $1.2 million ad buy featuring two spots on the issue, both zeroing in on pre-existing conditions. Cruz moved quickly to respond to the commercials, saying during a campaign stop Friday in Livingston that the super PAC is "saying something they know is false."

Democrats negotiating over President Barack Obama's 2010 health care measure wanted to force insurance companies to cover people with pre-existing conditions, generally considered a money-losing proposition and an unsustainable business model. So as a compromise, they also implemented a mandate forcing all Americans to secure health coverage or pay a fine, with the aim of pushing healthy, younger Americans into the health insurance market to help cover the costs of patients with pre-existing conditions.

That mandate was highly unpopular, and the Affordable Care Act was the driving force behind Democrats losing hundreds of state and federal legislative seats to Republicans who — like Cruz — vowed to repeal it. But once Republicans took power in 2017, they, too, ran into a policy buzzsaw. Their efforts to repeal Obamacare meant jeopardizing the popular pre-existing conditions provision.

In recent days, the issue has been a key division between candidates in Texas.

Recently while block walking in Richardson, Sessions spent eight minutes answering a single question on pre-existing conditions. He called Democratic charges that he would aim to eliminate pre-existing conditions “an absolute, despicable lie,” “a charade” and “shameless.”

He and other Republicans support forcing companies to cover patients with pre-existing conditions — but without the limits companies can charge customers that were included with the Affordable Care Act.

On Sunday in Houston, Culberson similarly disputed the honesty of the same charges against him.

“I am a co-author of legislation guaranteeing that people with pre-existing conditions are protected,” he said in a debate against his Democratic challenger, attorney Lizzie Fletcher.

“The alternative that we proposed for Obamacare to replace it included guaranteed coverage for people with pre-existing conditions,” he added.

But Fletcher fired back, arguing that the Republican plan this past term "may have nominally contained a provision that would allow you to maintain coverage for pre-existing conditions.

"So if your insurance can charge you 20 times more for insurance that you can’t afford, it’s not really available to you," she added. "If your monthly insurance premium is $15,000-20,000, then it's not really available to you."

Republican strategists monitoring the issue in Washington concede that health care has battered the party since it began its repeal push in 2017. But they also see hope in how many Democratic candidates are pushing for not just maintaining the 2010 health care law but for moving forward with single-payer health care, a system where the federal government uses tax money to pay for the health care of all residents. The concept was debated at length during Democratic primaries earlier this year, and the sound bites that resulted now comprise numerous GOP attack ads, some more truthful than others.

The tweet directs followers to a dead link, but an Allred spokeswoman provided to the Tribune the webpage and clarified that the hyperlinks had changed since the winter. The policy positions on the page provided stated, "The American people deserve the opportunity to choose a health care option that cuts out the insurance executives and puts people before profits."

Sessions said in a September debate that Allred supported a single-payer program, a charge Allred denied.

“There’s been an effort to associate [the term Medicare-for-all] with one thing, and it’s been used as a shorthand for many things.” Allred told the Tribune earlier this month, indicating he supported an option to buy government insurance that would compete with the private market.

"Single payer's a totally different thing," he added, saying that the U.S. government does not have the kinds of controls over the health care market necessary to make that program work.

In perhaps the most contentious example, Culberson’s campaign has run a number of ads accusing Fletcher of supporting a “complete government takeover of health care,” despite the fact Fletcher has expressed concerns about a single-payer system and has instead talked about adding a public option to Obamacare. For the claim, Culberson’s campaign points to a primary runoff debate where Fletcher said, “We need universal health care — not just health care coverage, not just health care insurance, but that we all need access to health care.”

“You’ve probably seen John Culberson’s negative ads about me — they’re ridiculous,” Fletcher says. “I don’t support a government takeover of health care.”

For Republicans, the attack is a little more straightforward in the 23rd District, where Jones “supports a single payer system” — the exact words on her campaign website. “A complete embracing of [that] is not something that my previous opponent had done,” Hurd said in an interview last month.

Another health care issue that has flared up in Texas’ hottest House races has been prescription drug prices. Culberson and Sessions have faced a batch of ads scrutinizing their votes against letting Medicare negotiate with pharmaceutical companies to lower drug prices, an idea long opposed by the GOP. Sessions in particular is being targeted by a super PAC called Patients for Affordable Drugs Action, which has poured over $600,000 into his race.

"Trump's dragging Congressman Sessions down in this suburban district, but Sessions' decades of siding with special interest folks, like these drug companies, may be what pulls him under,” said Jesse Ferguson, a Democratic strategist working for Patients for Affordable Drugs Action.

The group is not involved in Culberson’s district, but the issue is still percolating here. In September, Culberson joined other House Republicans in signing on to a letter asking House leaders to “repair and protect” Medicare Part D, the prescription drug coverage that he voted against in 2003. Like Allred did with Sessions’ pre-existing conditions resolution, Culberson’s challenger, Fletcher, criticized the letter as an 11th-hour effort by the incumbent to paper over his voting record.

The one thing the two parties have in common on this issue is that there has yet to be a political resolution to it once their side assumes ownership of revamping the American health care system.

Fletcher admitted so much about her party’s 2010 efforts.

"The Affordable Care Act, we know, is not perfect," she said. "We know there is work to be done."

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